Healthcare Provider Details

I. General information

NPI: 1447039235
Provider Name (Legal Business Name): IBTISAM OWAID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12813 W WARREN AVE
DEARBORN MI
48126-1532
US

IV. Provider business mailing address

12813 W WARREN AVE
DEARBORN MI
48126-1532
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-8090
  • Fax: 313-581-4823
Mailing address:
  • Phone: 313-581-8090
  • Fax: 313-581-4823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5601012109
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5601012109
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: